The public perception of major depressive disorder in South Asia: a literature review

Aims: To understand: the perception of depression as an illness in South Asia and the language used to describe it, its perceived aetiology, how individuals with depression are perceived by the community and the beliefs in the community surrounding the treatment of depression.

Methods: Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar. They were included if they discussed depression within the context of a South Asian culture.

Results: Depression is widely understood in South Asia as a disease with primarily somatic presentations stemming from stresses associated with difficult socioeconomic circumstances. Those with depression are often stigmatised but they are generally not excluded from the community. Alongside medical intervention, assistance from family and the community are the most accepted methods of addressing depression.

Conclusions: South Asian perceptions of depression accord with a psychosocial model of illness. Incorporating these perceptions is essential to the success of interventions and educational programs hoping to resonate with a general population and improve communication with health professionals.

Introduction
Depression, suffered by more than 300 million people worldwide, represents the single greatest contributor to global non-fatal health loss.[1, 2, 3] Its impacts are not limited to the Western world. While developed countries draw much of the research focus, the South Asian prevalence of depression was calculated at 26.3% based on primary care presentations.[1] In India in 2004 it accounted for a greater number of disability adjusted life years per 100,000 people than both cancer and diabetes mellitus combined.[1] Depression is particularly under-recognised and undertreated in rural areas.[4] The presentations, sequelae and understandings of depression are known to depend on culture, a relationship maintained in the South Asian context. [5, 6, 7, 8] Existing research highlights significant differences between developed and developing world perspectives on the disease—the extent to which depression is seen as somatic, the role of socioeconomic factors in its aetiology and community responsibilities in addressing it.[4] The strict biomedical conception of depression favoured by some health professionals may translate poorly across cultures and pose obstacles to improving recognition, treatment and education.[9] This paper aims to discuss general perceptions of depression in developing countries in South Asia. It will identify community views on: (1) depression as an illness, including the way it is described and presents; (2) its aetiology; (3) opinions about individuals with depression; and (4) beliefs about treatment. In synthesising the trends and repeating themes revealed by research, it hopes to provide a foundation for tailoring clinical and public health interventions to a South Asian cultural context.

Methods
Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar using the following keywords and MESH terms: Mental Disorders OR Depression; Developing Countries OR Asia OR Afghanistan OR India OR Sri Lanka OR Nepal OR Bhutan OR Maldives OR Pakistan; and Stigma, Public Perception, Understanding, OR Health Literacy. Studies were excluded if they were not published English language articles relating to depression in South Asian cultures.

Participants generally professed a poor medical understanding of depression and other mental illnesses. Many in the Liu et al. study (42.77%) could not answer what the word ‘depression’ meant to them.[4] In the Indian state of Maharashtra, 87.5% of community members did not acknowledge depression as a real medical illness.[10] However, participant groups frequently employed locally appropriate terminology when presented with a depression case study or vignette. Bangladeshi respondents referred to chinta rog or “worry illness”. [5] The Dari language speaks of asfurgdadi, the low mood and grief associated with hardships.[11] Using tailored vocabulary greatly improved communication between researchers and participants.[5] Both participants with depression and communities in general stressed the physical manifestations of the disease.[4, 5, 6, 9] The most commonly identified somatic symptoms associated with depression included fatigue, pain, numbness, sleeplessness, headache, breathlessness, and shaking.[5, 6, 9, 11] While several psychological symptoms were also listed,[5, 11] the physical aspects of the disease dominated and were often the main reasons to seek help.[6]

Aetiology of depression

An overwhelming majority of study participants described depression through a psychosocial understanding of its origins, emphasising the suffering individual’s social context. In rural Indian villages, depression is seen as an accumulation and escalation of grief or stress.[4] Many studies identified poverty and unemployment as major contributors to these pressures.[5, 6, 9] In Bangladesh it is believed that all tension rogs or “anxiety illnesses” are due to obhab, a (typically material) need of some kind caused by poverty.[5] Culturally specific financial stressors included an inability to provide dowry and education for all of one’s daughters.[5] Other stressors ranged from female reproductive problems and domestic violence to social inequality, injustice, and trauma.[4, 6, 9, 11] Refugees interviewed by Alemi et al. described language difficulties, family separations and cultural clashes.[11] A number of participants attributed depression to religious, supernatural or spiritual factors. A vignette about a woman with depression in Liu et al.’s study prompted participant theories about divine punishment and black magic.[4] Many raised the possibility of spiritual possession.[4] The Liu et al. study was an outlier in terms of biological explanations for aetiology— 54% of respondents linked depression to a disease of the brain and 33.8% believed it was inheritable.[4] The presentation of these options in a questionnaire, as opposed to the open-ended interviews of other studies, may have contributed to this divergence. But some of the external causative factors identified by participants, like “problems in the environment”[6] and polluted air,[4] also hint at a biological understanding of depression’s causes.

Perception of individuals with depression

Expressions of stigma were common. In two of the Indian studies the majority of individuals believed depression is a sign of weakness.[4, 10] In the Kermode et al. study,[10] 40% of community members concurred that people with depression are dangerous, 52.1% said they are erratic and 42.5% believed they should be avoided. Similarly, a large minority of respondents in the Liu et al. study described those with depression as unpredictable (43.8%), hard to talk with (40.5%), and a cause of familial shame (45.1%).[4] Despite this, most individuals expressed a willingness to remain the neighbours, friends and co-workers of someone with depression.[4, 10] These opinions were more likely in respondents who regarded depression as a “sign of weakness” instead of a genetic or biological disease. However, only 60.8% of participants were willing to accept someone with depression marrying into their family.[10] Bangladeshi respondents echoed these doubts about the marriage prospects of people with depression.[5]

Understandings of treatment

Most participants across the studies thought depression would be difficult—if not impossible—to remedy without assistance.[4, 10, 11] Pharmaceutical treatments were often poorly understood and warily regarded. Medication was restricted to treating the physical symptoms of depression.[9] Some participants were concerned about the addictive potential of using drugs to treat depression.[4] In Bangladesh, tablets were the option of last resort, partly due to cost.[5] Bangladeshi respondents instead prioritised poverty alleviation, good health and positive family relations.[5] Opinions of medical practitioners were generally positive. The patients in the Naeem et al. study professed a strong faith in doctors despite minimal awareness of their role in depression management and limited familiarity with non-pharmacological treatments like psychotherapy.[6] Sri Lankan undergraduate students who saw depression as a mental illness had confidence in medical experts[12] and refugees in Afghanistan also expressed faith in psychiatrists.[11] Opinions about traditional and religious healing modalities were mixed across the studies. In India, some respondents reported using herbal medicine to treat depression’s somatic symptoms,[9] and participants from Afghanistan sometimes consulted a tabib or herbal specialist.[11] A minority in the Indian, Bangladeshi, and Afghan samples identified religious practices, mantras and amulets as possible remedies.[5, 9, 11] Conversely, in another study, 63% of participants doubted traditional healers could successfully remedy depression, with more enthusiasm for their effectiveness only in conjunction with medical treatment.[4] None of the participants in the Pakistan study had visited a traditional healer, though one participant did recite passages from the Quran and perform the practice of do dum (or blowing air) on themselves as a form of self-help.[6] Several studies highlighted familial or social support as a particularly popular treatment option.[4, 5, 9] Bangladeshi respondents typically approached family members and close relatives before seeking help from other sources. Many of these individuals believed a community-based program would be the ideal way to address depression.[5] Other suggested treatments included involvement in communal activities,[5, 9] internal dialogue[9] and lifestyle changes such as eating right and exercising.[11] In Alemi et al., cultural activities, such as listening to Afghan music and visiting Afghanistan, were also named.[11]

Discussion

The reviewed literature suggests depression in South Asia is widely understood as a stress-related disease that emerges out of difficult socioeconomic circumstances and has primarily somatic manifestations. While those with depression are still subject to stigma, communal exclusion is rare.[4, 10] Familial and community assistance are the most accepted treatments for depression with medical intervention reserved for physical symptoms. [4, 5] South Asian respondents overwhelmingly favoured a psychosocial model of depression’s aetiology with minimal emphasis on biology. Empathy and understanding seemed highest when causal explanations of depression were linked to relatable hardships. Education campaigns and anti-stigma efforts may have more success if framed through this understanding of the disease compared to approaches rooted in biomedicine. In Kermode et al., individuals who related depression to a personal flaw (“weakness”) or extrinsic factors (e.g., family and financial problems) were less likely to socially distance themselves from people with depression compared to those who believed in a biological cause.[10] Biology may be seen to imply a lack of agency and the possibility of hereditary transmission, both of which negatively impact marriage prospects. This aetiological understanding of depression affects the acceptance of pharmacological interventions. While Indian respondents used pharmacological treatments for somatic symptoms, and drugs are seen as a valid last resort in Bangladesh,[5] the expense and arcane mechanisms of action of antidepressants may compromise adherence when they are prescribed. Nonpharmacological methods might be more acceptable despite remaining mostly unheard of in more rural areas. A study on university students in Pakistan, for example, found that cognitive behavioural therapy could be successful in that population provided interventions are tailored to South Asian cultural and religious values.[13] As depression is commonly attributed to external socioeconomic factors, programs addressing these wider social issues may reduce its prevalence. Studies investigating poverty alleviation as an intervention for depression have reported conflicting results in Uganda and Mexico.[14, 15] The evidence suggests depression interventions demand a multi-faceted approach. The importance of family and the community support for individuals with depression was a motif across the reviewed studies. South Asian countries are characterised by collectivistic cultures emphasising close family ties.[16] While family and the community participation in interventions can be extremely beneficial, the isolation and interpersonal conflict associated with stigma can be especially damaging. Community-based interventions were the ideal approach for participants in the Selim et al. study.[5] Education campaigns targeting the family and communities around individuals with depression may be fruitful.

Limitations

Due to the limited body of research on this topic as it relates to this region, not every South Asian country could be represented in this review. The included studies cannot be interpreted as reflecting universally held beliefs within their respective countries. The review also only included English-language studies, narrowing its scope further and perhaps excluding significant contributions from local research. It is possible participants were reluctant to openly share their traditional and religious beliefs with medical professionals or as part of a scientific study, resulting in their underrepresentation.[6]

Conclusion

This review aimed to present a general overview of how depression is perceived in the developing countries of South Asia. Considering these synthesised findings may help shape future public health efforts seeking greater success in improving education about depression and its treatment and prevention—in South Asia, and potentially in other developing countries where depression is similarly understood.